Russell Street Dental ClinicNHS Waiting List Todays Date* Date Format: DD slash MM slash YYYY Your Date of Birth* DD MM YYYY Are you exempt from NHS Dental ChargeS? Yes No Unsure Reason you are exempt (ie Under 18 aged 18 and in full-time education, Income Support, Pension CreditGuarantee, Income Based JSA, Income Based ESA, Tax Credit exemption card or certificate, Universal Credit,HC2 certificate, Pregnant or had a baby within the last 12 months). Enter if knownDate of last Dental visit ( approx )Name/location of previous dental clinic ( If known )Are you experiencing pain? Yes No Maybe Name* First Last Address* Street Address Address Line 2 City ZIP / Postal Code Mobile / Contact Number*Email Telephone number(house)NationalityFirst languageOther family members, at same address, who are looking for NHS dental care/treatment:Date of Birth DD MM YYYY Full NameDate of Birth DD MM YYYY Full NameDate of Birth DD MM YYYY Full NameDate of Birth DD MM YYYY Full NameDate of Birth DD MM YYYY Full NameDate of Birth DD MM YYYY Full NameI consent to my submitted data being collected and stored. We will never share this information with any third parties.* Please Tick Box To Agree EmailThis field is for validation purposes and should be left unchanged.